Provider Demographics
NPI:1669585402
Name:R L LAKE DDS INC
Entity type:Organization
Organization Name:R L LAKE DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT R L LAKE DDS INC
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-567-3961
Mailing Address - Street 1:200 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2402
Mailing Address - Country:US
Mailing Address - Phone:918-567-3961
Mailing Address - Fax:918-567-3424
Practice Address - Street 1:200 DALLAS ST
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2402
Practice Address - Country:US
Practice Address - Phone:918-567-3961
Practice Address - Fax:918-567-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty